Funds exam 3 Ch: 10, 37, 38, 39, 40

A nurse is explaining a chest tube to family members who do not understand where it is placed. What would the nurse tell them? A) "It is inserted into the space between the lining of the lungs and the ribs." B) "I don't exactly know, but I will make sure the doctor comes to explain." C) "It is inserted directly into the lung itself, connecting to a lung airway." D) "It is inserted into the peritoneal space and drains into the lungs."

Ans: A Feedback: A chest tube is a firm plastic tube with drainage holes in the proximal end that is inserted into the pleural space, thus allowing compressed lung tissue to re-expand.

What information do anthropometric measurements provide in adults? A) Indirect measure of protein and fat stores B) Direct measure of degree of obesity C) Indication of degree of growth rate D) Reflection of social interaction with others

Ans: A Feedback: Anthropometric measurements are used to determine body dimensions. In children, they are used to assess growth rate; in adults, they give indirect measurements of body protein and fat stores.

A nurse is caring for a client with pneumonia. The client's oxygen saturation is below normal. What abnormal respiratory process does this demonstrate? A) changes in the alveolar-capillary membrane and diffusion B) alterations in the structures of the ribs and diaphragm C) rapid decreases in atmospheric and intrapulmonic pressures D) lower-than-normal concentrations of environmental oxygen

Ans: A Feedback: Any change in the surface area of the lungs hinders diffusion of gas exchange. Any disease or condition that results in changes in the alveolar-capillary membrane, such as pneumonia or pulmonary edema, makes diffusion more difficult, assessed by decreased oxygen saturation measurement.

The nurse is developing a plan of care for a client admitted with pneumonia. The nurse has determined that a priority nursing diagnosis for this client is "Ineffective Airway Clearance related to copious and tenacious secretions." Based upon this nursing diagnosis, what is an appropriate nursing intervention to include in the client's care plan? A) Encouraging the client to consume two to three quarts of clear fluids daily B) Creating an environment that is likely to reduce anxiety C) Posi

Ans: A Feedback: Clients can help keep their secretions thin by drinking two to three quarts (1.9 L to 2.9 L) of clear fluids daily. Although it is important to create an environment that is likely to reduce a client's anxiety, doing so will not assist in promoting airway clearance. The nurse should not encourage the client to decrease the number of cigarettes smoked daily, but should encourage the client to stop smoking. Proper positioning to ease respirations includes placing the client in a high- Fowler's position.

A client is experiencing hypoxia. Which of the following nursing diagnoses would be appropriate? A) Anxiety B) Nausea C) Pain D) Hypothermia

Ans: A Feedback: Clients who are hypoxic commonly experience anxiety and restlessness related to feelings of suffocation.

The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of A) Atelectasis B) Bronchospasm C) Croup D) Epiglottitis

Ans: A Feedback: Stiffer lungs tend to collapse and their alveoli also collapse. This condition is called atelectasis.

In planning to meet the nutritional needs of a critically ill client in the intensive care unit, which factor will increase the client's basal metabolic rate? A) Infection B) Advanced age C) Prolonged fasting D) Long periods of sleep

Ans: A Feedback: Factors that increase a person's basal metabolic rate (BMR) include growth, infections, fever, emotional tension, extreme environmental temperatures, and elevated levels of certain hormones (epinephrine and thyroid hormones). Aging, prolonged fasting, and sleep all decrease BMR.

A nurse is caring for a young adult female client who has a folic acid defiency. When teaching the client about this condition, the nurse would include a discussion about the client's increased risk for which of the following? A) Neural tube deficits in the fetus B) Inadequate absorption of calcium and phosphorus C) Hemolysis of red blood cells D) Impaired neuromuscular functioning

Ans: A Feedback: Folic acid deficiency in pregnant women can lead to neural tube deficits like spina bifida in the fetus. Because fetal neural development begins so early in pregnancy, women in their childbearing years must have adequate folic acid intake. Deficiency in vitamin D intake leads to inadequate absorption of calcium and phosphorus, and a deficiency of mineralization in bones and teeth. Increased hemolysis of red blood cells, poor reflexes, impaired neuromuscular functioning, and anemias are signs of vitamin E deficiency, not folic acid deficiency.

Which of the following are signs and symptoms of poor nutritional status? A) Flaky facial skin, facial edema, pale skin color B) Tongue is a deep red in color with surface papillae present. C) Firm, pink nailbeds D) Firm hair that is resistant to plucking

Ans: A Feedback: Healthy skin is uniform in color and not swollen.

While the nurse is providing morning hygiene for a client who has a chest tube, the client has rolled over quickly and the chest tube has become disconnected from the drainage unit. How should the nurse first respond to this event? A) Submerge the end of the tube in sterile water. B) Clamp the tube near the end and also near the insertion point. C) Place the end of the tube on a sterile surface and seek help promptly. D) Clean the end of the tube with an alcohol swab and reconnect it to the drai

Ans: A Feedback: If a chest tube becomes disconnected from the drainage unit, the nurse should submerge the end of the tube in a bottle of sterile water, thus preventing a pneumothorax but still allowing air to escape.

Which of the following laboratory results indicates the presence of malnutrition? A) Serum albumin 2.8 g/dL B) Hemoglobin (Hgb) 11.3 g/dL C) Creatinine 1.9 mg/dL D) Hematocrit (Hct) 56%

Ans: A Feedback: Increased Hct indicates dehydration.

A nurse is educating a preoperative client on how to effectively deep breathe. Which of the following would be included? A) "Make each breath deep enough to move the bottom ribs." B) "Breathe through the mouth when you inhale and exhale." C) "Breathe in through the mouth and out through the nose." D) "Practice deep breathing at least once each week."

Ans: A Feedback: Instruct the client to make each breath deep enough to move the bottom ribs. Start with deep breaths by inhaling through the nose and exhaling through the mouth. Deep breathing should be done hourly when awake, or four times a day.

The nurse is testing the blood glucose levels of a client with a history of diabetes. The nurse has performed hand hygiene, checked the order, informed the client and turned on the monitor. After removing a test strip from the vial, the nurse should do which of the following? A) Confirm that the strip and the meter share the same code. B) Massage the client's finger toward the selected puncture site. C) Cleanse the client's finger with alcohol. D) Pierce the client's skin with the lancet.

Ans: A Feedback: It is important to confirm that the code on the strip and the meter match. This should precede massaging and cleansing the client's finger or piercing his/her skin.

The ANA, which is committed to monitoring the regulation, education, and use of NAPs, recommends adherence to which one of the following principles? A) It is the nursing profession that determines the scope of nursing practice. B) It is the RN who defines and supervises the education, training, and use of any unlicensed assistant roles. C) It is the assigned NAP who is responsible and accountable for his or her nursing practice. D) It is the purpose of the RN to work in a supportive role to the assistive personnel.

Ans: A Feedback: It is the nursing profession that determines the scope of nursing practice, and defines and supervises the education, training, and use of any unlicensed assistant roles involved in providing direct nursing care. It is the registered nurse who is responsible and accountable for nursing practice, and who supervises any assistant involved in providing direct client care. It is the purpose of assistive personnel to work in a supportive role to the registered nurse, carrying out tasks that enable the professional nurse to concentrate on caring for the client.

Which of the following diseases may result in decreased lung compliance? A) Emphysema B) Appendicitis C) Acne D) Chronic diarrhea

Ans: A Feedback: Lung compliance refers to the stretchability of the lungs, or the ease with which lungs can be inflated. Emphysema, a chronic lung disease, and the normal changes associated with aging are examples of conditions that result in decreased elasticity of lung tissue, which in turn decreases lung compliance.

Which of the following nutritional guidelines should a nurse provide to a client who is entering the second trimester of her pregnancy? A) "You'll need to eat more calories and to make sure you eat a balanced diet high in nutrients." B) "Try to eat your normal number of calories, but aim to eat a diet that's higher in fruits and vegetables." C) "The more food energy you consume, the greater the chances that you will have a healthy pregnancy." D) "Maintain your regular calorie i

Ans: A Feedback: Nutrient needs during pregnancy increase to support growth and maintain maternal homeostasis, particularly during the second and third trimesters. During the last two trimesters, women of normal weight need approximately 300 extra calories per day. Key nutrient needs include protein, calories, iron, folic acid, calcium, and iodine. It would be inaccurate to encourage the client to maximize calorie intake.

A dietitian is providing an in-service for the nurses on a medical-surgical unit. During the in-service, she informs the group that there are six classes of nutrients, and three supply the body with energy. What are the three sources of energy? A) Carbohydrates, protein, and lipids B) Vitamins, minerals, and water C) Carbohydrates, protein, and water D) Lipids, vitamins, and minerals

Ans: A Feedback: Of the six classes of nutrients, three supply energy (carbohydrates, protein, and lipids), and three are needed to regulate body processes (vitamins, minerals, and water).

The home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. What additional assessment would the nurse expect to observe? A) Crackles in the lower lobes B) Inspiratory stridor C) Expiratory stridor D) Wheezing in the upper lobes

Ans: A Feedback: People with chronic congestive heart failure often experience shortness of breath because of excess fluid in the lungs and low oxygen levels. Stridor is associated with respiratory infections such as croup. Wheezing may be heard in individuals who use tobacco products.

The nursing instructor informs a student nurse that a client she is caring for has a chronic neurologic condition that decreases the client's peristalsis. What nursing diagnosis is the most likely risk for this client? A) Constipation B) Diarrhea C) Deficient fluid volume D) Excessive fluid volume

Ans: A Feedback: Peristalsis is defined as the contractions of the circular and longitudinal muscles of the intestine. Decreased peristalsis will result in constipation because the movement of the fecal mass will occur at a slower rate and more fluid will be absorbed in the colon.

An older woman who is a resident of a long-term care facility has to get up and void several times during the night. This can be the result of what physiologic change with normal aging? A) Diminished kidney ability to concentrate urine B) Increased bladder muscle tone causing urinary frequency C) Increased bladder contractility causing urinary stasis D) Decreased intake of fluids during daytime hours

Ans: A Feedback: Physiologic changes that accompany normal aging may affect urination in older adults. These changes include the diminished ability to concentrate urine that may result in nocturia (voiding during the night). Aging does not result in increased bladder muscle tone or increased bladder contractility. A decrease in fluid intake would not result in nocturia.

For which of the following clients should the nurse anticipate the need for a pureed diet? A) A man whose stroke has resulted in difficulty swallowing B) A woman who has required gallbladder surgery C) A man with dementia who is unable to follow instructions D) An obese woman after bariatric surgery

Ans: A Feedback: Pureed diets are indicated for clients who have significant problems chewing and/or swallowing. Surgery and confusion are not indications for this change in the texture and consistency of food.

A nurse performing a nutritional assessment determines that the BMI of a 5'11" (1.8 meters) male client who weighs 81 kilograms is which of the following? A) 25.1 B) 18.5 C) 20.3 D) 28.6

Ans: A Feedback: The formula for calculating BMI is (body weight in kilograms) divided by (body height in meters squared). (weight in kg) (height in meters) * (height in meters)

A woman 90 years of age has been in an automobile crash and sustained four fractured ribs on the left side of her thorax. Based on her age and the injury, she is at risk for what complication? A) Pneumonia B) Altered thought processes C) Urinary incontinence D) Viral influenza

Ans: A Feedback: The normal changes in the respiratory system associated with aging (such as rigidity of tissues and airways and decreased movement of the diaphragm) coupled with fractured ribs would increase the risk of pneumonia in an older adult.

The nurse caring for a client with emphysema has determined that a priority nursing diagnosis for this client is "Imbalanced Nutrition: Less Than Body Requirements related to difficulty breathing while eating." Based upon this diagnosis, which of the following is an appropriate nursing intervention to include in the client's care plan? A) Provide six small meals daily. B) Provide three large meals daily. C) Encourage the client to eat immediately before breathing treatments. D) Encourage t

Ans: A Feedback: The nurse should consider providing six small meals distributed over the course of the day instead of three large meals. Meals should be eaten one to two hours after breathing treatments and exercises.

The nurse caring for a client for several days has assessed that he has been eating poorly during his hospitalization. Which nursing measure should the nurse implement to assist the client in improving his nutritional intake? A) Encourage his daughter to prepare food at home and bring it to the client. B) Serve large meals and encourage the client to eat as much as possible. C) Provide distractions while the client is fed so that he will eat more. D) Provide bland meals.

Ans: A Feedback: The nurse should solicit food preferences and encourage favorite foods from home, when possible. Be sure the foods look attractive and the eating area is free of odors, clutter, and distractions during mealtime. Provide small, frequent meals to avoid overwhelming the client with large amounts of food.

Most nutritionists recommend increasing fiber in the diet. In addition to other benefits, how does fiber affect cholesterol? A) Increases fecal excretion of cholesterol B) Decreases fecal excretion of cholesterol C) Facilitates intake and use of trans fat D) Raises blood cholesterol levels

Ans: A Feedback: To help lower serum cholesterol levels, researchers recommend limiting cholesterol intake, eating less total fat, eating more unsaturated fat, and increasing fiber intake. Fiber increases fecal excretion of cholesterol.

A nurse is following a physician's order to irrigate the NG tube of a client. Which of the following is a recommended guideline in this procedure? A) Assist client to 30- to 45-degree position, unless this is contraindicated. B) Draw up 60 mL of saline solution (or amount indicated in the order or policy) into syringe. C) If Salem sump or double-lumen tube is used, make sure that syringe tip is placed in the blue air vent. D) If unable to irrigate the tube, reposition client and attempt irriga

Ans: A Feedback: To irrigate an NG tube, assist the client to 30- to 45-degree position, unless this is contraindicated. Pour the irrigating solution into the container and draw up 30 mL of saline solution (or amount indicated in the order or policy) into syringe. If Salem sump or double-lumen tube is used, make sure that syringe tip is placed in the drainage port and not in the blue air vent. If unable to irrigate the tube, reposition the client and attempt irrigation again. Inject 10 to 20 mL of air and aspirate again.

A client is interested in losing 15 pounds, and she informs the nurse she is counting her calorie intake each day. The client has a goal of losing one pound a week until she reaches her goal. The client asks the nurse how many calories she should decrease daily to lose a pound a week. What is the nurse's best response? A) 500 calories/day B) 200 calories/day C) 300 calories/day D) 400 calories/day

Ans: A Feedback: To lose 1 pound (0.45 kg) in a week, daily calorie intake should be decreased by 500 calories a day. One pound of body fat equals about 3,500 calories; 3,500 calories divided by 7 days = 500 calories/day.

A nurse is caring for a client with a history of cardiac and vascular disease. Which of the following fats should the nurse allow in the client's diet for his condition? A) Unsaturated fats B) Trans fats C) Saturated fats D) Hydrogenated fats

Ans: A Feedback: Unsaturated fat is a healthier form of fat than saturated fat, because it contains less hydrogen, and therefore can be included in the client's diet. Saturated fats are lipids that contain as much hydrogen as their molecular structure can hold, and are generally solid. Most saturated fats are found in animal sources, such as the marbled fat in meat. Saturated fats are responsible for cardiac and vascular diseases. Trans fats are unsaturated fats that have been hydrogenated, a process in which hydrogen is added to the fat. Consumption of trans fats, saturated fats, and hydrogenated fats increases the risk of coronary heart disease.

An emergency room nurse is auscultating the chest of a child who is having an asthmatic attack. Auscultation reveals the presence of wheezes. During what part of respirations do wheezes occur? A) Inspiration and expiration B) Only on inspiration C) Only on expiration D) When coughing

Ans: A Feedback: Wheezes are continuous sounds heard on expiration and sometimes on inspiration. They originate as air passes through airways constricted by swelling (as in asthma), secretions, or tumors.

A nurse is conducting a health promotion program for adolescents to educate them about the hazards of smoking. When describing the effects on the respiratory system, which of the following would the nurse most likely include? A) Decreased production of mucus B) Inhibition of mucus removal C) Increase in the mucous escalator D) Inhibition of bacterial colonization

Ans: B Feedback: Smoking inhibits mucus removal. By producing more mucus and by slowing the mucous escalator, smoking inhibits mucus removal and can cause airway blockage, promoting bacterial colonization and infection.

A nurse uses a nasal cannula to deliver oxygen to a client who is extremely hypoxic and has been diagnosed with chronic lung disease. What is the most important thing to remember when using a nasal cannula? A) It can cause the nasal mucosa to dry in case of high flow. B) It can cause anxiety in clients who are claustrophobic. C) It can create a risk of suffocation. D) It can result in an inconsistent amount of oxygen.

Ans: A Feedback: When using a nasal cannula to deliver oxygen to a client, the nurse should remember that the nasal cannula can cause the nasal mucosa to dry in case of high oxygen flow. A simple mask can cause anxiety in clients who are claustrophobic. Clients using a partial rebreather mask are at risk of suffocation. A face tent may deliver an inconsistent amount of oxygen, depending on environmental loss.

What type of leadership can a graduate nurse working in a magnet hospital expect? A) Democratic B) Autocratic C) Situational D) Quantum

Ans: A Feedback: Working in a magnet hospital can maximize the potential of new graduates who prefer democratic leadership.

The nursing student is working to improve his time management. Which of the following would assist the nursing student in accomplishing his goal? Choose all that apply. A) Identify priorities for the day. B) Evaluate time management at the end of the day. C) Establish a reasonable time line. D) Plan to arrive right at start of shift. E) Plan on his cohorts helping him

Ans: A, B, C Feedback: Establish goals and priorities for each day. The nurse should identify what needs to be accomplished each day, differentiating need to do from nice to do tasks. Then nurse should establish a time line so that it is clearly evident when he or she is falling behind schedule, in time to correct it. The nurse should evaluate success or failure and use the results to plan the next day 's time management. The nurse should plan to arrive at least 15 minutes or more before the start of shift so that he or she can be prepared to receive change of shift report. Then nurse should plan time to assist his cohorts instead of them helping him. The cohorts may be too busy to assist or may need assistance themselves.

A nurse is attempting to change the method for documenting client care in a hospital setting. Which of the following should be considered before planning change? Select all that apply. A) What is amenable to change? B) How does the group function as a unit? C) Is the group ready for change? D) Are the changes major or minor? E) How can I keep from changing again?

Ans: A, B, C, D Feedback: Before planning to make a change, a nurse manager should consider the following; What is amenable to change? Considering this question might reveal a behavior not amenable to change. How does the group function as a unit? Is the person or group ready for change and, if so, at what rate can that change be expected to be accepted? Are the changes major or minor? A series of small changes might be more easily accomplished than one large, dramatic change. Change is inevitable; a more appropriate question to ask is how often this change needs to be evaluated.

Which of the following factors increase BMR? Select all that apply. A) Growth B) Infections C) Fever D) Emotional tension E) Aging

Ans: A, B, C, D Feedback: Factors that increase BMR include growth, infections, fever, emotional tension, extreme environmental temperatures, and elevated levels of certain hormones, especially epinephrine and thyroid hormones. Aging, prolonged fasting, and sleep all decrease BMR.

A head nurse assumes the leadership role when directing and supervising coworkers. Which of the following are attributes of a leader? Select all that apply. A) Philosophical B) Task-oriented C) Charismatic D) Dynamic E) Intimidating

Ans: A, C, D Feedback: Leadership involves philosophy, perception, and judgment whereas management tasks are the core of the management role. Leaders need to be comfortable with themselves (i.e., have a positive self-image) and present themselves as role models for followers. Ideally, they also have a vision that energizes the group and brings forth the best efforts of members. Leaders may be charismatic, dynamic, enthusiastic, poised, confident, and self-directed.

A nurse is caring for an older adult client who is to be discharged from the health care facility. The client has been prescribed the use of a liquid oxygen unit at home to continue with oxygen therapy. What should the nurse tell the client regarding the potential problems of using a liquid oxygen unit? Select all that apply. A) Liquid oxygen may leak during warm weather. B) The unit may give off a bad smell if not cleaned regularly. C) The unit's outlet may become occluded because of frozen m

Ans: A, C, D Feedback: The nurse should inform the client who has been prescribed the use of a liquid oxygen unit that the unit may leak during warm weather; frozen moisture may occlude the outlet; and the unit is more expensive when compared with other portable sources of oxygen. Emission of a bad smell if filters are not cleaned, increase in the electric bill, and requirement of a secondary source of oxygen in case of failure are disadvantages of using an oxygen concentrator and are not related to the use of a liquid oxygen unit.

A client visits the health care facility for a scheduled physical assessment. What should the nurse do when physically assessing the quality of the client's oxygenation? Select all that apply. A) Monitor the client's respiratory rate. B) Note the amount of oxygen administered. C) Check the symmetry of the client's chest. D) Observe the breathing pattern and effort. E) Check the devices used to deliver oxygen.

Ans: A, C, D Feedback: When physically assessing the quality of the client's oxygenation, the nurse should monitor the client's respiratory rate, check the symmetry of the client's chest, and observe the breathing pattern and effort of the client. The nurse should also auscultate for lung sounds. Additional assessments include recording the heart rate and blood pressure, determining the client's level of consciousness, and observing the color of the skin, mucous membranes, lips, and nailbeds. However, the nurse does not note the amount of oxygen administered to the client, or check the device that is used to deliver oxygen to the client during the physical assessment.

A nurse has documented that a client has anorexia. What does this term mean? A) Eating more than daily requirements B) Lack of appetite C) Vitamin C deficiency D) Fluid deficit

Ans: B Feedback: Anorexia is lack of appetite. It may be related to multiple factors, including diseases, psychosocial causes, impaired ability to chew and taste, or inadequate income.

A nurse is educating a client who has congested lungs how to keep secretions thin, and more easily coughed up and expectorated. What would be one self-care measure to teach? A) Limit oral intake of fluids to less than 500 mL per day. B) Increase oral intake of fluids to two to three quarts per day. C) Maintain bed rest for at least three days. D) Take warm baths every night for a week.

Ans: B Feedback: Clients can keep their secretions thin by drinking two to three quarts (1.9 L to 2.9 L) of clear fluids daily. Fluid intake should be increased to the maximum the client's health state can tolerate.

To promote health of the fetus, the nurse should instruct the woman in the first trimester of pregnancy to do which of the following? A) Eliminate high-fiber foods B) Eat foods high in folic acid C) Consume saturated fats D) Consume milk products in the last trimester

Ans: B Feedback: Folic acid deficiency in pregnant women can lead to neural tube deficits in the fetus. Women during pregnancy may experience constipation. Increased fiber intake is recommended. Saturated fats are to be eaten only in moderation. Milk products are important during the entire pregnancy

A nurse is caring for a client with complaints of chest pain. Which of the following test results would indicate whether the client is at risk for cardiac disease? A) Test results of levels of unsaturated fats B) Test results for dyslipidemia C) Test results of levels of balanced proteins D) Test results of levels of calories in each food intake

Ans: B Feedback: Health care providers test for dyslipidemia to assess clients' risks for cardiovascular disease. Measuring levels of protein, calories, or unsaturated fats will not help to assess if a client is at risk for cardiac and vascular disease.

When comparing team nursing with functional nursing, what characteristic is found? A) Team nursing is very similar to functional nursing. B) Team nursing focuses on individual client care. C) Functional nursing has a stronger focus on the client. D) Functional nursing is based on total client care.

Ans: B Feedback: In team nursing, a registered nurse and other caregivers provide care to a designated group of clients for a given shift. Team nursing modifies the depersonalized approach of functional nursing and focuses on individual client care.

What information would a home care nurse provide to a client who is measuring peak expiratory flow rate at home? A) "Although the test is uncomfortable, it is not painful." B) "You will be asked to forcefully exhale into a mouthpiece." C) "The test is used to determine how much air you inhale." D) "You will do this each morning while still lying in bed."

Ans: B Feedback: Peak expiratory flow rate (PEFR) refers to the volume of air that can be forcibly exhaled. While sitting or standing, the client takes a deep breath and forcibly exhales through a mouthpiece. The client does this three times, and the highest number is recorded. Clients commonly measure PEFR at home to monitor airflow when they have conditions such as asthma.

Which individual is at greater risk for respiratory illnesses from environmental causes? A) A farmer on a large farm B) A factory worker in a large city C) A woman living in a small town D) A child living in a rural area

Ans: B Feedback: Researchers have demonstrated a high correlation between air pollution and lung diseases, including cancer. Air pollution puts people with certain occupations, and those who live in large cities, at a greater risk for these diseases.

A nurse is inserting an indwelling urethral catheter. What type of supplies will the nurse need for this procedure? A) A clean catheter and rubber gloves B) A sterile catheterization kit or tray C) Solutions to sterilize the urethra D) Solutions to sterilize the vagina

Ans: B Feedback: The bladder is a sterile environment. The urethra and vagina cannot be sterilized. The equipment used for catheterization is usually prepackaged in a sterile disposable kit or tray.

A nurse is educating a postoperative client on how to use an incentive spirometer. Which of the following is an accurate step that should be included in the teaching plan? A) Instruct the client to inhale normally and then place the lips securely around the mouthpiece. B) Instruct the client to inhale slowly and as deeply as possible through the mouthpiece, without using the nose. C) When the client cannot inhale anymore, the patient should hold his or her breath and count to 10. D) Encourage th

Ans: B Feedback: The client using an incentive spirometer should exhale normally and place the lips around the mouthpiece. He or she should inhale slowly and deeply without using the nose, and when the client cannot inhale anymore, hold the breath and count to 3 before exhaling normally. This should be performed 5 to 10 times every one to two hours, if possible.

The nurse prepares to administer an intermittent feeding to a client who has a nasogastric feeding tube. Arrange the following steps in the correct order 1. Verify correct tube placement. 2. Position client with head of bed elevated 30 to 45° degrees 3. Aspirate all gastric contents. 4. Flush tube with 30 mL water. 5. Verify that residual volume is less than 400 mL. 6. Administer feeding. A) 1, 2, 3, 4, 5, 6 B) 2, 1, 3, 5, 4, 6 C) 2, 3, 1, 4, 6, 5 D) 1, 3, 2, 4, 5, 6 E) 1, 4, 2, 3, 5, 6

Ans: B Feedback: The correct order for administering an intermittent feed to a client who has a nasogastric feeding tube is (1) Position client with head of bed elevated 30 to 45° degrees; (2) Verify correct tube placement; (3) Aspirate all gastric contents; (4) Verify that residual volume is less than 400 mL; (5) Flush tube with 30 mL water; and (6) Administer feeding.

A nurse is caring for a toddler who is having an acute asthmatic attack with copious mucus and difficulty breathing. The child's skin is cyanotic, respirations are labored and rapid, and pulse is rapid. What nursing diagnosis would have priority for care of this child? A) Anxiety B) Ineffective Airway Clearance C) Excess Fluid Volume D) Disturbed Sensory Perception

Ans: B Feedback: The nursing diagnosis Ineffective Airway Clearance indicates the child is unable to clear secretions or obstructions from the respiratory tract to maintain a clear airway. Although the child is anxious, this is not the priority of care. The other two diagnoses are not supported by the data.

A father of a preschool-age child tells the nurse that his child "has had a constant cold since going to daycare." How would the nurse respond? A) "Your child must have a health problem that needs medical care." B) "Children in daycare have more exposure to colds." C) "Are you washing your hands before you touch the child?" D) "Be sure and have your child wear a protective mask at school."

Ans: B Feedback: The preschool-age child's eustachian tubes, bronchi, and bronchioles are elongated and less angular. Thus, the average number of routine colds and infections increases when the child enters daycare or school and is exposed more frequently to pathogens.

A hospitalized client has been NPO with only intravenous fluid intake for a prolonged period. What assessments might indicate protein-calorie malnutrition? A) Fever, joint pain, dehydration B) Poor wound healing, apathy, edema C) Sleep disturbances, anger, increased output D) Weight gain, visual deficits, erythema of skin

Ans: B Feedback: The stress of illness, surgery, or prolonged periods of time on simple intravenous therapy without oral intake places hospitalized clients at risk for developing protein-calorie malnutrition. This can result in weakness, poor wound healing, mental apathy, and edema.

During a health history interview, a male client tells the nurse that he does not feel that he completely empties his bladder when he voids. He has been diagnosed with an enlarged prostate. What is the name of this symptom? A) Urinary incontinence B) Urinary retention C) Involuntary voiding D) Urinary frequency

Ans: B Feedback: Urinary retention occurs when urine is produced normally but is not excreted completely from the bladder. Factors associated with urinary retention include medications, an enlarged prostate, or vaginal prolapse. Incontinence is involuntary loss of urine from the bladder. Retention is an accumulation of urine in the bladder. Frequency is voiding more often than usual.

A physician prescribes the use of water-seal chest tube drainage for a client at a health care facility. What should the nurse ensure when using the water-seal chest tube drainage? A) Filters need to be cleaned regularly to avoid unpleasant taste or smell. B) The chest tube should not be separated from the drainage system unless clamped. C) A nasal cannula should be used to administer oxygen when cleaning the opening. D) A secondary source of oxygen should be available in case of power failure.

Ans: B Feedback: When using water-seal chest tube drainage, the nurse should never separate the chest tube from the drainage system unless clamped. Even then, the tube should be clamped only briefly. When using an oxygen concentrator as a source of oxygen, the nurse should clean the filter regularly to avoid an unpleasant taste or smell. A secondary source of oxygen should also be available in case of a power failure. When cleaning a transtracheal catheter, oxygen needs to be administered with a nasal cannula.

A nurse researching a diet for a client with diabetes includes foods that supply energy to the body. Which of the following are classes of nutrients that supply this energy? Select all that apply. A) Vitamins B) Proteins C) Fats D) Minerals E) Carbohydrates

Ans: B, C, E Feedback: Of the six classes of nutrients, three supply energy (carbohydrates, proteins, lipids [fats]) and three are needed to regulate body processes (vitamins, minerals, water).

Then nurse is preparing to apply a fecal incontinence pouch. Arrange the following steps in the correct order. 1. Cleanse entire perianal area and pat dry. 2. Apply skin protectant and allow it to dry. 3. Separate buttocks and apply the pouch to the anal area. 4. Attach the pouch to a urinary drainage bag. 5. Hang the drainage bag below the patient.. A) 2, 3, 4, 5, 1 B) 3, 4, 5, 1, 2 C) 1, 2, 3, 4, 5 D) 5, 4, 3, 2, 1

Ans: C Feedback: A nurse would not be able to determine if the entire intestinal tract is clear

What prevents air from re-entering the pleural space when chest tubes are inserted? A) The location of the tube insertion B) The sutures that hold in the tube C) A closed water-seal drainage system D) Respiratory inspiration and expiration

Ans: C Feedback: After insertion, the chest tube is secured with a suture and tape, covered with an airtight dressing, and usually attached to a closed water-seal drainage system that prevents air from reentering the pleural space.

A physician orders a retention enema for a client to destroy intestinal parasites. Which of the following enemas would be indicated for this client? A) Oil retention enema B) Carminative enema C) Anthelmintic enema D) Nutritive enema

Ans: C Feedback: Anthelmintic enemas are administered to destroy intestinal parasites. Oil retention enemas help to lubricate the stool and intestinal mucosa, making defecation easier. Carminative enemas help to expel flatus from the rectum and relieve distention. Nutritive enemas are administered to replenish fluids and nutrition rectally.

A nurse calculates the BMI of a client during a general survey as 26. Under which of the following categories would this client fall? A) Underweight B) Normal C) Overweight D) Obesity Class I

Ans: C Feedback: BMI values are: Underweight <18.5; normal 18.5 to 24.9; overweight 25.0 to 29.9; obesity class I 30.0 to 34.9; obesity class II 35.0 to 39.9; and extreme obesity 40.0+.

A client is taking diuretics. What should the nurse teach the client about his urine? A) Urinary output will be decreased. B) Urinary output will be increased. C) Urine will be a pale yellow color. D) Urine may be brown or black.

Ans: C Feedback: Certain drugs cause the urine to change color. Diuretics can lighten the color of urine to pale yellow. The nurse should inform the client about this side effect of the medication.

A nurse is caring for a client who suddenly begins to have respiratory difficulty. In what position would the nurse place the client to facilitate respirations? A) Supine B) Prone C) High-Fowler's D) Dorsal recumbent

Ans: C Feedback: During inspiration, the diaphragm contracts and descends, lengthening the thoracic cavity. This movement is facilitated by a high-Fowler's position in which the abdominal contents move downward, providing more room for the descent of the diaphragm and greater lung expansion.

A nurse is caring for a client with excessive abdominal fat. Which of the following is a risk associated with excessive abdominal fat about which the nurse should inform the client? A) Emaciation B) Cachexia C) Cardiovascular disease D) Anorexia

Ans: C Feedback: Excess abdominal fat may lead to cardiovascular disease, hypertension, and diabetes. Anorexia is the loss of appetite. Emaciation is characterized by excessive leanness. Cachexia is the general wasting away of body tissue.

Which client will have an increased metabolic rate and require nutritional interventions? A) A healthy young adult who works in an office B) A retired person living in a temperate climate C) A person with a serious infection and fever D) An older, sedentary adult with painful joints

Ans: C Feedback: Factors that increase metabolic rate include growth, infections, fever, emotional tension, extreme environmental temperatures, and elevated levels of some hormones. Aging, prolonged fasting, and sleep decrease metabolic rate.

A senior student has been elected president of the Student Nurses Association. Which of the following qualities is essential to being a nursing leader? A) Physical stamina B) Physical attractiveness C) Flexibility D) Independence

Ans: C Feedback: Flexibility is a must for all nurse leaders. The needs of clients, families, and the nursing team can change from minute to minute. Leaders of nursing organizations must also demonstrate the characteristics of a nursing leader.

A nurse is ordered to perform digital removal of stool on a client with stool impaction. Which of the following is an appropriate step in this procedure? A) Position the client in supine position as dictated by client comfort and condition. B) Insert generously lubricated finger gently into the anal canal, pointing away from the umbilicus. C) Gently work the finger around and into the hardened mass to break it up and then remove pieces of it. D) Instruct the client not to bear down while extract

Ans: C Feedback: For digital removal of stool: Position the client on the left side (Sims' position), as dictated by client comfort and condition. Generously lubricate index finger with water-soluble lubricant and insert finger gently into anal canal, pointing toward the umbilicus. Gently work the finger around and into the hardened mass to break it up and then remove pieces of it. Instruct the client to bear down, if possible, while extracting feces, which will ease in removal.

In general, how do most people view change? A) By how it affects the cohesiveness of the group B) By how much it will cost in time and resources C) By how they are affected personally D) By how it will affect others on the staff

Ans: C Feedback: In general, people view change in terms of how they are affected personally. Examples include threats to self-esteem, amount of work required, and effect on social relationships.

A nurse is assessing the urine on a newborn's diaper. What would be a normal assessment finding? A) Scanty to no urine B) Highly concentrated urine C) Light in color and odorless D) Dark in color and odorous

Ans: C Feedback: Infants are born with little ability to concentrate urine. An infant's urine is usually very light in color and without odor until about 6 weeks of age, when the nephrons are able to control reabsorption of fluids and effectively concentrate urine. Infants do not normally have scanty, highly concentrated, or dark and odorous urine.

A nutritionist helps to plan a diet for a client with diabetes. Which of the following foods is a carbohydrate that should be included to help improve glucose tolerance? A) Milk B) Eggs C) Oatmeal D) Nuts

Ans: C Feedback: Oatmeal is a water-soluble carbohydrate that helps improve glucose tolerance in diabetics. Milk, eggs, and nuts are proteins.

A nurse is helping a client design a weight-loss diet. To lose one pound of fat (3,500 calories) per week, how many calories should be decreased each day? A) 100 B) 250 C) 500 D) 1,000

Ans: C Feedback: One pound of body fat equals about 3,500 calories. To gain or lose one pound in a week, daily calorie intake should be reduced by 500 calories per day (3,500 calories divided by 7 = 500 calories per day).

A nurse manager has encountered resistance to a planned change. What is one way the nurse can overcome the resistance? A) Tell the staff that if they don't like it, they can quit. B) Implement change rapidly and all at once. C) Encourage open communication and feedback. D) Let the staff know that the change is mandated.

Ans: C Feedback: Providing opportunities for open communication and feedback is one way to overcome resistance to change.

What does pulse oximetry measure? A) Cardiac output B) Peripheral blood flow C) Arterial oxygen saturation D) Venous oxygen saturation

Ans: C Feedback: Pulse oximetry is a noninvasive technique that measures the oxygen saturation of arterial blood. The normal range is 95% to 100%. It does not measure cardiac output, peripheral blood flow, or venous oxygen saturation.

Of all factors, what is the most important risk factor in pulmonary disease? A) Air pollution from vehicles B) Dangerous chemicals in the workplace C) Active and passive cigarette smoke D) Loss of the ozone layer of the atmosphere

Ans: C Feedback: The effects of both active and passive cigarette smoke increase airway resistance, reduce ciliary action, increase mucus production, and thicken alveolar-capillary membranes and bronchial walls. Cigarette smoke is the most important risk factor in pulmonary disease.

A client has had a head injury affecting the brain stem. What is located in the brain stem that may affect respiratory function? A) Chemoreceptors B) Stretch receptors C) Respiratory center D) Oxygen center

Ans: C Feedback: The medulla in the brain stem, immediately above the spinal cord, is the respiratory center. Stretch receptors are located in muscles. Chemoreceptors that affect respirations are located in the aortic arch and the carotid bodies.

A client visits a health care facility with complaints of loss of appetite following a prolonged illness. How should the nurse document the client's condition? A) Emaciation B) Cachexia C) Anorexia D) Nausea

Ans: C Feedback: The nurse should document the loss of appetite following prolonged illness as anorexia. Emaciation is excessive leanness. Cachexia is the general wasting away of body tissue. Nausea usually precedes vomiting and is associated with gastrointestinal sensations.

What independent nursing intervention can be implemented to stimulate appetite? A) Administer prescribed medications. B) Recommend dietary supplements. C) Encourage or provide oral care. D) Assess manifestations of malnutrition.

Ans: C Feedback: There are many methods of stimulating appetite in a client to prevent malnutrition. One independent nursing intervention that is useful is to encourage or provide oral care.

A nurse is delivering oxygen to a client via an oxygen mask. Which of the following is a recommended guideline for this procedure? A) Adjust the mask so it fits tightly around the face. B) For a mask with a reservoir, fill the reservoir half-full of oxygen. C) Remove the mask and dry the skin every two to three hours if the oxygen is running continuously. D) If the client is experiencing redness around the mask, remove and apply powder to the mask.

Ans: C Feedback: To apply an oxygen mask, position the facemask over the client's nose and mouth and adjust the elastic strap so that the mask fits snugly, but comfortably, on the face. For a mask with a reservoir, be sure to allow oxygen to fill the bag before proceeding to the next step. Remove the mask and dry the skin every two to three hours if the oxygen is running continuously; do not use powder around the mask.

A nurse is caring for a client who is postoperative Day 1 for a temporary colostomy. The nurse assesses no feces in the collection bag. What should the nurse do next? A) Notify the physician immediately. B) Ask another nurse to check her findings. C) Nothing; this is normal. D) Recheck the bag in two hours.

Ans: C Feedback: Typically, a colostomy does not produce drainage or feces until normal peristalsis returns after surgery, usually within two to five days.

A nurse has instructed a client at the clinic about collecting a specimen for a routine urinalysis. The client makes the following statements. Which one indicates a need for more teaching? A) "I need to tell you that I am having my menstrual period." B) "I will void into the specimen bottle you gave me." C) "I will keep the toilet paper in the specimen." D) "I will be sure that no stool is included in my urine."

Ans: C Feedback: Urine for a routine urinalysis does not have to be sterile. Ask the client to void into a clean receptacle and avoid contamination with stool. Note on the request form if a woman is having her menstrual period. Instruct clients not to put toilet paper into the urine because this makes analysis more difficult.

What category of medications may be administered by nebulizer or metered-dose inhaler to open narrowed airways? A) Bronchoconstrictors B) Antihistamines C) Narcotics D) Bronchodilators

Ans: D Feedback: A nebulizer is used to adminster medications in the form of an inhaled mist. Bronchodilators are medications that may be administered by nebulizer or metered-dose inhaler to open narrowed airways. Antihistamines are not administered via nebulizer; they are prescribed to manage allergy-related symptoms. Narcotics are not administered via nebulizer; they are used to manage complaints of pain.

A nurse is beginning to conduct a health history for a client with respiratory problems. He notes that the client is having respiratory distress. What would the nurse do next? A) Continue with the health history, but more slowly. B) Ask questions of the family instead of the client. C) Conduct the interview later and let the client rest. D) Initiate interventions to help relieve the symptoms.

Ans: D Feedback: Before beginning the interview for a health history, the nurse should ascertain that the client is not in acute distress. If the client is experiencing any respiratory distress, the nurse immediately initiates interventions to help relieve symptoms.

A client has been prescribed a clear liquid diet. What food or fluids will be served? A) Milk, frozen dessert, egg substitutes B) High-calorie, high-protein supplements C) Hot cereals, ice cream, chocolate milk D) Jell-O, carbonated beverages, apple juice

Ans: D Feedback: Clear liquid diets contain only foods that are clear liquids at room or body temperature. Included are gelatin, fat-free broth, bouillon, ice pops, clear juices, carbonated beverages, regular and decaffeinated coffee, and tea. A full liquid diet includes all fluids and foods that become liquid at room temperature. This would include ice cream, chocolate milk, and liquid dietary supplements.

A nurse assessing a client with an ostomy appliance documents the condition "prolapse" in the client chart and notifies the physician. Which of the following statements describes this condition? A) The peristomal skin is excoriated or irritated because the appliance is cut too large. B) The system has leaks or poor adhesion leading to noticeable odor. C) The bag continues to come loose and become inverted. D) The stoma is protruding into the bag and may become twisted.

Ans: D Feedback: During prolapse, the stoma is protruding into the bag. The nurse should have the client rest for 30 minutes and, if stoma is not back to normal size within that time, notify the physician. If stoma stays prolapsed, it may twist, resulting in impaired circulation to the stoma.

A nurse is delegating the collection of urinary output to an assistant. What should the nurse tell the assistant to do while measuring the urine? A) Compare the amount of output with intake. B) Use a clean measuring cup for each voiding. C) Tell the client to wash the urethra before voiding. D) Wear gloves when handling a client's urine.

Ans: D Feedback: Gloves are required when handling urine to prevent exposure to pathogenic microorganisms or blood that may be present in the urine. In addition, goggles are also worn if there is a concern of urine splashing.

In Lewin's classic theory of change, what happens during unfreezing? A) Planning is conducted. B) Change is initiated. C) Change becomes operational. D) The need for change is recognized.

Ans: D Feedback: In Lewin's change theory, during unfreezing the need for change is recognized. Unfreezing does not include planning, initiating, or operationalizing change.

A client has been taught how to do Kegel exercises. What statement by the client indicates a need for further information? A) "I understand these will help me control stress incontinence." B) "I know this is also called pelvic floor muscle training." C) "I will do these 30 to 80 times a day for two months." D) "I will contract the muscles in my abdomen and thighs."

Ans: D Feedback: Kegel exercises, or pelvic floor muscle training, are used to tone and strengthen the muscles that support the bladder. They can improve voluntary control of urination and thus improve or eliminate stress incontinence. The muscles to contract are the same ones used to stop urination midstream or control defecation. The client should not contract the muscles of the abdomen, inner thigh, or buttocks while doing Kegel exercises.

A client is discussing weight loss with a nurse. The patient says, "I will not eat for two weeks, then I will lose at least 10 pounds." What should the nurse tell the client? A) "What a good idea. Go ahead. That will jump start your weight loss!" B) "Many people find that to be an ideal way to lose weight quickly and easily." C) "That will increase your metabolic rate and help you lose weight." D) "That will decrease your metabolic rate and make weight loss more difficult."

Ans: D Feedback: Most nutritionists agree that fasting or following a very low-calorie diet defeats a weight-loss plan because the body interprets this eating pattern as starvation, and compensates by slowing down the basal metabolic rate, making it even more difficult to lose weight.

Which of the following tasks could the nurse safely delegate to unlicensed assistive personnel? A) An initial assessment of a client B) Determination of a nursing diagnosis C) Evaluation of client progress D) Documentation of client's I+O on a flow sheet

Ans: D Feedback: Nursing care or tasks that should never be delegated except to another RN include (Ayers & Montgomery, 2008) the following: the initial and ongoing nursing assessment of the client and his or her nursing care needs; the determination of the nursing diagnosis, nursing care plan, evaluation of the client's progress in relation to care plan, and evaluation of the nursing care delivered to the client; the supervision and education of nursing personnel; client education that requires an assessment of the client and his or her education needs; and any other nursing intervention that requires professional nursing knowledge, judgment, and/or skill.

A nurse is discussing infant care with a woman who just had a baby girl. What type of nutrition would the nurse recommend for the infant? A) Solid foods after the first month B) No solid foods until age 1 year C) Bottle feeding with cow's milk D) Breast-feeding or formula with iron

Ans: D Feedback: Nutritional needs per unit of weight are greater in infants than at any other time in the life cycle. Breast-feeding or a commercial formula with iron is recommended as the major source of nutrition for the first 6 to 12 months of life. Cow's milk is not recommended for infants under 1 year. Solid foods are usually not introduced until 6 months.

What is occult blood? A) Bright red visible blood B) Dark black visible blood C) Blood that contains mucus D) Blood that cannot be seen

Ans: D Feedback: Occult blood in the stool is blood that is hidden in the specimen or cannot be seen on gross examination. It can be detected with simple screening tests, such as a Hematest.

A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this procedure? A) Using upper chest muscles more effectively B) Replacing the use of incentive spirometry C) Reducing the need for p.r.n. pain medications D) Prolonging expiration to reduce airway resistance

Ans: D Feedback: Pursed-lip breathing can help clients with dyspnea and feelings of panic gain control of their respirations. This exercise trains the muscles to prolong expiration, increasing airway pressure during expiration, and reducing the amount of airway trapping and resistance.

What is the route of administration for TPN? A) Oral B) Subcutaneous C) Intramuscular D) Intravenous

Ans: D Feedback: TPN meets the client's nutritional needs by way of nutrient-filled solutions administered intravenously through a central line, usually the subclavian or internal jugular veins.

A physician is choosing a chest drainage system for a client who is ambulating daily. Which of the following systems would be the best choice for this client? A) Traditional water seal B) Wet suction C) Dry suction water seal D) Dry suction/one-way valve system

Ans: D Feedback: The dry suction or one-way valve system works even if knocked over, making it ideal for clients who are ambulatory.

A nurse is feeding a client. Which of the following statements would help a person maintain dignity while being fed? A) "I am going to feed you your cereal first, and then your eggs." B) "I wish I had more time so I could feed you all of your meal." C) "I know you don't like me to feed you, but you need to eat." D) "What part of your dinner would you like to eat first?"

Ans: D Feedback: The loss of independence that comes with the inability to self-feed can be a severe blow to a person's self-esteem. Asking the person his or her preference regarding the order of items eaten can help maintain dignity while being fed.

In what age group would a nurse expect to assess the most rapid respiratory rate? A) Older adults B) Middle adults C) Adolescents D) Infants

Ans: D Feedback: The normal infant's chest is small and the airways are short. There are fewer and smaller alveoli in infants. As a result, the respiratory rate is more rapid in infants than any other age group.

A nurse assesses the vital signs of a healthy newborn infant. What respiratory rate could be expected based on the developmental level of this client? A) 15 to 25 breaths/minute B) 16 to 20 breaths/minute C) 20 to 44 breaths/minute D) 30 to 55 breaths/minute

Ans: D Feedback: The normal range for an infant's breath per minute is 30 to 60.

How often would a nurse recommend a client eat or drink a source of vitamin C? A) Once a week B) Once a month C) Three times a week D) Every day

Ans: D Feedback: Vitamin C, a water-soluble vitamin, is usually not stored in the body. Deficiency symptoms are apt to develop quickly when intake is inadequate; a daily intake is recommended.

While reviewing an adult client's chart, a nurse notes average daily intake of fluids as 2,000 mL/day. What will the nurse do based on this information? A) Change the plan of care to include forcing fluids. B) Ask the client to drink more water during the day. C) Post a sign limiting fluids to 1,000 mL every 24 hours. D) Continue with care; this is a normal fluid intake.

Ans: D Feedback: Water intake averages 2,000 to 2,500 mL/day for adults. The nurse would continue with care, because the client has a normal fluid intake.

A nurse is assessing the stools of a breastfed baby. What is the appearance of normal stools for this baby? A) Yellow, loose, odorless B) Brown, paste-like, some odor C) Brown, formed, strong odor D) Black, semiformed, no odor

Ans: A Feedback: Breast-fed babies have more frequent stools, and the stools are yellow to golden and loose, usually with little odor. Breast-fed babies can normally have 2 to 10 stools per day.

The nurse has just graduated with a Bachelor of Science in Nursing and is eager to find a mentor at this early stage in her career. Which of the following individuals is most likely to be an appropriate mentor for the nurse? A) An experienced nurse who was a preceptor in a previous clinical placement B) The nurse educator on the hospital unit where the novice nurse has been hired C) A colleague who graduated with honors at the same time as the novice nurse. D) The unit manager who the novice nur

Ans: A Feedback: A person who demonstrates positive qualities and who possesses more experience is often a good choice to be a nurse's mentor. A person in formal authority or oversight, such as the unit educator or manager, is a less ideal choice, and a peer is not normally an ideal choice of mentor.

A client with urine retention related to a complete prostatic obstruction requires a urinary catheter to drain the bladder. Which type of catheter is most appropriate for a client that has an obstructed urethra? A) Suprapubic catheter B) Indwelling urethral catheter C) Intermittent urethral catheter D) Straight catheter

Ans: A Feedback: A suprapubic catheter is used for long-term continuous drainage and is inserted through a small incision above the pubic area. Suprapubic bladder drainage diverts urine from the urethra when injury, stricture, prostatic obstruction, or abdominal surgery has compromised the flow of urine through the urethra.

While caring for an infant who is breast-fed, the nurse assesses the characteristics of the stools. What stool characteristics are expected in breast-fed infants? A) Golden yellow and loose B) Dark brown and firm C) Yellow-brown and pasty D) Green and mucusy

Ans: A Feedback: Breast-fed infants have more frequent stools, and the stools are yellow to golden, loose, and usually have little odor. With formula or cow's milk feedings, infants' stools vary from yellow to brown and are pasty in consistency.

Which is an expected outcome for a client undergoing a bowel training program? A) Have a soft, formed stool at regular intervals without a laxative. B) Continue to use laxatives, but use one less irritating to the rectum. C) Use oil-retention enemas on a regular basis for elimination. D) Have a formed stool at least twice a day for two weeks.

Ans: A Feedback: Clients who have chronic constipation and impaction, and those who are incontinent of stool, may benefit from a bowel training program. The purpose of this program is to manipulate factors within the client's control (such as exercise or fluid intake) to produce the elimination of a soft, formed stool at regular intervals without a laxative.

A nurse strives to establish trusting interpersonal relationships with clients, peers, subordinates, and superiors to facilitate goal achievement and personal growth of all participants. Which type of skills is this nurse demonstrating? A) Communication skills B) Problem-solving skills C) Management skills D) Self-evaluation skills

Ans: A Feedback: Communication skills involve the ability to establish trusting interpersonal relationships with clients, peers, subordinates, and superiors to maximize goal achievement and enhance the personal growth. Problem-solving skills refer to the ability to analyze all sides of a problem, to suspend judgment, to explore multiple options, and to work toward a creative solution. Management skills pertain to the ability to direct others toward goal achievement. Selfevaluation skills involve the ability to assess honestly one's effectiveness, to accept both praise and criticism, and to direct personal professional growth and development.

What type of leader shares decisions and activities with group participants? A) Democratic B) Autocratic C) Laissez-faire D) Situational

Ans: A Feedback: Democratic leadership, also called participative leadership, is characterized by equality among the leader and other participants. Decisions and activities are shared.

A patient has developed edema in her lower legs and feet, prompting her physician to prescribe furosemide (Lasix), a diuretic medication. After the client has begun this new medication, what should the nurse anticipate? A) Increased output of dilute urine B) Increased urine concentration C) A risk of urinary tract infections D) Transient incontinence and increased urine production

Ans: A Feedback: Diuretics result in moderate to severe increases in the production of dilute urine. Concentration will decrease, not increase, and there is no accompanying risk of urinary tract infections. For some clients, this sudden increase in urine output may precipitate transient incontinence, but this remains an abnormal finding.

The nurse is having an exceptionally busy shift on an obstetrical unit. Which of the following tasks is the nurse justified in delegating to an unlicensed care provider? A) Emptying a client's Foley catheter bag and reporting the volume to the nurse B) Helping a first-time mother achieve a good latch when breast-feeding her infant C) Assessing the size and quantity of clots that are in a client's bedpan and informing the nurse D) Giving an anti-inflammatory to a client who is eight hours pos

Ans: A Feedback: Emptying a Foley catheter bag and reporting the volume is within the scope of an unlicensed care provider. Assistance with breast-feeding, assessments, and medication administration are not tasks that should be delegating to anyone but an RN.

A male client who has had outpatient surgery is unable to void while lying supine. What can the nurse do to facilitate his voiding? A) Assist him to a standing position. B) Tell him he has to void to be discharged. C) Pour cold water over his genitalia. D) Ask his wife to assist with the urinal.

Ans: A Feedback: Helping clients assume their usual voiding positions may be all that is necessary to resolve an inability to void. If male clients cannot void lying down, encourage them to void while standing at the bedside unless this is contraindicated.

After surgery, a postoperative client has not voided for eight hours. Where would the nurse assess the bladder for distention? A) Between the symphysis pubis and the umbilicus B) Over the costovertebral region of the flank C) In the left lower quadrant of the abdomen D) Between ribs 11 and 12 and the umbilicus

Ans: A Feedback: When the bladder is distended with urine, it rises above the symphysis pubis and may reach to just below the umbilicus. The other choices are anatomically incorrect for assessing a distended bladder.

A nurse is assessing the urine output of a client with Parkinson's disease who is on levodopa. Which of the following is a common finding for a client on this medication? A) The urine may be brown or black. B) The urine may be blood-tinged. C) The urine may be green or blue-green. D) The urine may be orange or orange-red.

Ans: A Feedback: Levodopa (l-dopa), an antiparkinson drug, and injectable iron compounds can lead to brown or black urine. Anticoagulants may cause hematuria (blood in the urine), leading to a pink or red color. Diuretics can lighten the color of urine to pale yellow. Phenazopyridine (Pyridium), a urinary tract analgesic, can cause orange or orange-red urine.

A student nurse has just graduated with a baccalaureate degree in nursing. What type of nursing leadership will this nurse be expected to provide? A) Nursing care of the individual client B) Demonstration of selected critical skills C) Ability to be a follower rather than a leader D) Nursing care of groups of clients

Ans: A Feedback: New graduates have leadership responsibilities when they begin nursing. Nursing leadership begins with nursing care of the individual client.

A nurse is scheduling diagnostic studies for client. Which test would be performed first? A) Fecal occult blood test B) Barium study C) Endoscopic exam D) Upper gastrointestinal series

Ans: A Feedback: Nurses are commonly involved in scheduling diagnostic studies when a client is to undergo multiple studies. They should follow a logical sequence when more than one test is required for accurate diagnosis; that is, fecal occult blood tests to detect gastrointestinal bleeding; barium studies to visualize gastrointestinal structures and reveal any inflammation, ulcers, tumors, strictures, or other lesions; and endoscopic examinations to visualize an abnormality, locate a source of bleeding, and if necessary, provide biopsy tissue samples.

A client tells the nurse that he takes laxatives every day but is still constipated. The nurse's response is based on: A) Habitual laxative use is the most common cause of chronic constipation. B) If laxatives are not effective, the client should begin to use enemas. C) A laxative that works by a different method should be used. D) Chronic constipation is nothing to be concerned about.

Ans: A Feedback: Occasional use of laxatives is not harmful for most people, but they should not become dependent on them. Although many people do take laxatives because they believe they are constipated, most are unaware that habitual use of laxatives is the most common cause of chronic constipation.

A nurse is using a bladder scanner to assess the bladder volume of a client with urinary frequency. In which of the following positions would the nurse place the client? A) Supine B) Sims' C) High Fowler's D) Dorsal recumbent

Ans: A Feedback: Portable bladder ultrasound devices are accurate, reliable, and noninvasive devices used to assess bladder volume. Results are most accurate when the client is in the supine position during the scanning.

A nurse is described as a "quantum leader." Which action characterizes this type of leadership? A) A nurse conducts a blind survey to evaluate her leadership skills. B) A nurse relinquishes power to a group deciding hospital policy. C) A nurse makes policy decisions for coworkers without consulting them. D) A nurse sticks to the "tried and true" methods when implementing client care.

Ans: A Feedback: Quantum leaders must have excellent communication skills, encourage personal critiques, and challenge current ways of thinking and doing. A nurse who relinquishes power to a group to make decisions is using laissez-faire leadership. A nurse making decisions for coworkers without considering their feelings is an autocratic leader.

Nurses with varying levels of experience possess leadership skills. A graduate nurse walks out of the nurse manager's office after a meeting. The graduate nurse reflects on the positive and negative feedback that she received from the manager regarding her three months working on the unit. What nursing leadership skill is best illustrated by the graduate nurse in this scenario? A) Self-evaluation skills B) Communication skills C) Problem-solving skills D) Management skills

Ans: A Feedback: Self-evaluation skills incorporate the ability to assess honestly one's effectiveness, to accept both praise and criticism, and to direct personal professional growth. Communication skills demonstrate the ability to establish trusting interpersonal relationships with clients, peers, subordinates, and superiors to maximize goal achievement. Problem-solving skills include the ability to analyze all sides of a problem, to suspend judgment, to explore multiple options, and to work toward a creative solution. Management skills are the ability to direct others toward goal achievement.

Which of the following nursing care tasks is acceptable for a graduate nurse to delegate to unlicensed assistive personnel (UAP)? A) Assisting a client with ambulation B) Evaluation of nursing care delivered to a client C) Initial and ongoing assessments D) Development of a client teaching plan

Ans: A Feedback: Tasks that should be performed by a registered nurse include initial and ongoing assessments, determining nursing diagnoses, plan of care, evaluation of client progress, evaluation of the nursing care delivered to the patient, supervision and education of nursing personnel, and client education. Tasks such as ambulation, assistance with meals and hygiene, and obtaining vital signs are acceptable tasks for a UAP to perform.

A nurse is documenting the appearance of feces from a client with a permanent ileostomy. Which of the following would she document? A) "Ileostomy bag half filled with liquid feces." B) "Ileostomy bag half filled with hard, formed feces." C) "Colostomy bag intact without feces." D) "Colostomy bag filled with flatus and feces."

Ans: A Feedback: The client with an ileostomy (temporary or permanent) has an opening into the small intestine. Because feces do not reach the large intestine, water is not absorbed, and the feces will be liquid.

A nurse is initiating a 24-hour urine collection for a client at home. What will be the first thing the nurse will ask the client to do at the beginning of the specimen collection? A) Void and discard the urine. B) Begin the collection at a specific time. C) Add the first voiding to the specimen. D) Keep the urine warm during collection.

Ans: A Feedback: The collection is initiated at a specific time, but the client is asked to void at that time and discard the urine from the first voiding. In most instances, a preservative is added to the collection bottle, or the collected urine is kept cold through refrigeration or putting it on ice.

A nurse assesses the abdomen of a client before and after administering a small-volume cleansing enema. What condition would be an expected finding? A) Increased bowel sounds B) Abdominal tenderness C) Areas of distention D) Muscular resistance

Ans: A Feedback: The goal of a cleansing enema is to increase peristalsis, which should increase bowel sounds.

A nurse is assessing a client with constipation and severe rectal pain. Which of the following actions should the nurse perform to determine the presence of fecal impaction? A) Inserted a lubricated, gloved finger into the rectum. B) Obtain a sharp intestinal x-ray. C) Insert a lubricated rectal tube into the rectum. D) Administer an oil retention enema into the rectum.

Ans: A Feedback: The nurse should insert a lubricated, gloved finger into the rectum to determine the presence of fecal impaction. Fecal impaction occurs when a large, hardened mass of stool interferes with defecation. Obtaining a sharp intestinal x-ray is not a good idea because the barium retained in the intestine causes fecal impaction. Insertion of a rectal tube and administration of an oil retention enema are measures used to remove hardened stool, not assess it.

Which of the following describes the term micturition? A) Emptying the bladder B) Catheterizing the bladder C) Collecting a urine specimen D) Experiencing total incontinence

Ans: A Feedback: The process of emptying the bladder is known as urination, micturition, or voiding.

A client tells the nurse, "Every time I sneeze, I wet my pants." What is this type of involuntary escape of urine called? A) Urinary incontinence B) Urinary incompetence C) Normal micturition D) Uncontrolled voiding

Ans: A Feedback: The process of emptying the bladder is termed micturition, voiding, or urination. Sometimes increased abdominal pressure, such as occurs when sneezing or coughing, forces an involuntary escape of urine, especially in women because the urethra is shorter. Any involuntary loss of urine that causes such a problem is referred to as urinary incontinence.

The nurse is assessing a client with abdominal complaints. The nurse performs deep palpation of the abdomen for which reason? A) Detect abdominal masses B) Determine abdominal firmness C) Assess softness of abdominal muscles D) Assess degree of abdominal distention

Ans: A Feedback: The purpose of the deep palpation is to detect abdominal masses. Light palpation of the abdomen helps to determine the firmness or softness of the abdominal muscles and the degree of abdominal distention.

During a visit to the pediatrician's office, a parent inquires about toilet training her daughter age 2 years. The nurse informs the mother that one factor in determining toilet-training readiness is when ... A) the child can recognize bladder fullness. B) the child can hold the urine for four to five hours. C) The child cannot control urination until seated on the toilet. D) The child ignores the desire to void.

Ans: A Feedback: Toilet training usually begins around ages 2 or 3 years. Toilet training should not begin until the child is able to hold urine for two hours, recognize the feeling of bladder fullness, communicate the need to void, and control urination until seated on the toilet.

An older adult woman has constant dribbling of urine. The associated discomfort, odor, and embarrassment may support which of the following nursing diagnoses? A) Social Isolation B) Impaired Adjustment C) Defensive Coping D) Impaired Memory

Ans: A Feedback: Urinary incontinence is a special problem for older adults who may have decreasing control over micturition, or find it more difficult to reach the toilet in time. The discomfort, odor, and embarrassment of urine-soaked clothing can greatly diminish a person's self-concept, causing him or her to feel like a social outcast.

What are two essential techniques when collecting a stool specimen? A) Hand hygiene and wearing gloves B) Following policies and selecting containers C) Wearing goggles and an isolation gown D) Using a no-touch method and toilet paper

Ans: A Feedback: Use of medical aseptic techniques when collecting a stool specimen is imperative. Hand hygiene, before and after wearing rubber gloves, is essential.

During defecation, the client experiences decreased cardiac output related to the Valsalva maneuver. After the Valsalva maneuver, the nurse assesses the client's vital signs and expects to observe which of the following? A) An increase in the client's blood pressure B) A decrease in the client's blood pressure C) An increase in the client's respiratory rate D) A decrease in the client's respiratory rate

Ans: A Feedback: When an individual bears down to defecate, the increased pressures in the abdominal and thoracic cavities result in a decreased blood flow and a temporary decrease in cardiac output. Once the bearing down ceases, the pressure is lessened, and a larger than normal amount of blood returns to the heart; this act elevates the client's blood pressure.

The nurse is a manager on an orthopedic unit. The unit changed to a new computer documentation system three days ago. One of the night nurses has called in sick every shift since the new system started. The nursing manager is aware that this situation has to do with resistance to change. Which of the following are common reasons why people resist change? Choose all that apply. A) Feel threatened B) Fear increased responsibility C) Lack of understanding D) See no benefits to the change E) Dislike hospital chief officer

Ans: A, B, C, D Feedback: The most common reasons people resist change are threat to self, lack of understanding, fear of increased responsibility, envisioning a lack of benefits to the change, and being unable to tolerate working in a state of flux. Dislike of the hospital CEO is not a common reason to resist change.

The home health nurse is caring for an older adult woman living alone at home who is incontinent of urine and changes her adult diaper daily. Which of the following nursing diagnoses is the most appropriate for this client? A) Risk for activity intolerance B) Risk for impaired skin integrity C) Risk for infection D) Risk for falls

Ans: B Feedback: A client who is incontinent, utilizes adult diapers, and only changes them daily is at Risk for Impaired Skin Integrity in the genital and perineal area.

A client is on bedrest, and an enema has been ordered. In what position should the nurse position the client? A) Fowler's B) Sims' C) Prone D) Sitting

Ans: B Feedback: A reclining position on the left side (Sims' position) is recommended. The head may be slightly elevated, but Fowler's position should be avoided because the solution will remain in the rectum and expulsion will occur rapidly, resulting in minimal cleansing.

Planned change is a purposeful, systematic effort to alter or bring about change. What occurs next after alternative solutions to a problem are determined and analyzed? A) All of the alternative solutions are implemented. B) A course of action is chosen from among the alternatives. C) The effects of the change are evaluated. D) The change is stabilized and established.

Ans: B Feedback: After determining and analyzing alternative solutions to a problem, select a course of action from the possible alternatives. It is best to avoid initiating too many courses of action and thereby dissipating resources and energy.

A client has had frequent watery stools (diarrhea) for an extended period of time. The client also has decreased skin turgor and dark urine. Based on these data, which nursing diagnosis would be appropriate? A) Imbalanced Nutrition: Less than Body Requirements B) Deficient Fluid Volume C) Impaired Tissue Integrity D) Impaired Urinary Elimination

Ans: B Feedback: Bowel elimination problems may also affect other areas of human functioning. For example, excessive diarrhea causes loss of body fluid, with resulting decreased skin turgor and concentrated urine. Deficient Fluid Volume is an appropriate nursing diagnosis based on the data.

A man with urinary incontinence tells the nurse he wears adult diapers for protection. What risks should the nurse discuss with this client? A) Public embarrassment B) Skin breakdown and UTI C) Inability to control urine D) Odor and leakage

Ans: B Feedback: Clients frequently turn to absorbent products for protection when they are incontinent of urine and if they have not had this condition properly diagnosed and treated. When used improperly, such products may cause skin breakdown and place the client at risk for a UTI.

A nurse is providing discharge instructions for a client with a new colostomy. Which of the following is a recommended guideline for long-term ostomy care? A) During the first six to eight weeks after surgery, eat foods high in fiber. B) Drink at least two quarts of fluids, preferably water, daily. C) Use enteric-coated or sustained-release medications if needed. D) Use a mild laxative if needed.

Ans: B Feedback: During the first six to eight weeks after surgery, the nurse should encourage the client with an ostomy to avoid foods high in fiber (e.g., foods with skins, seeds, and shells) as well as any other foods that cause diarrhea or excessive flatus. By gradually adding new foods, the ostomy client can progress to a normal diet. The nurse should urge clients to drink at least two quarts of fluids, preferably water, daily. The use of liquid, chewable, or injectable forms rather than long-acting, enteric-coated, or sustained-release medications is recommended. Laxatives and enemas are dangerous because they may cause severe fluid and electrolyte imbalance.

A client is admitted to the health care facility with complaints of pain on urination that is secondary to a urinary tract infection (UTI). The nurse documents this finding as which of the following? A) Polyuria B) Dysuria C) Nocturia D) Hematuria

Ans: B Feedback: Dysuria means painful voiding. Pain is often associated with UTIs and is felt as a burning sensation during urination. Polyuria is the formation and excretion of excessive amounts of urine in the absence of a concurrent increase in fluid intake. Voiding during normal sleeping hours is called nocturia. Hematuria refers to blood in the urine.

A young woman has just consumed a serving of ice cream pie and develops severe cramping and diarrhea. The school nurse suspects the woman is ... A) Allergic to sugar B) Lactose intolerant C) Experiencing infectious diarrhea D) Deficient in fiber

Ans: B Feedback: Many people have difficulty digesting lactose (the sugar contained in milk products). The breakdown of lactose into its component sugars, glucose and galactose, requires a sufficient quantity of the enzyme lactase in the small intestine. If a person is lactose-deficient, alterations of bowel elimination, including formation of gas, abdominal cramping, and diarrhea, can occur after ingestion of milk products.

A client is having difficulty having a bowel movement on the bedpan. What is the physiologic reason for this problem? A) It is painful to sit on a bedpan. B) The position does not facilitate downward pressure. C) The position encourages the Valsalva maneuver. D) The cause is unknown and requires further study.

Ans: B Feedback: Most people assume the squatting or slightly forward-sitting position with the thighs flexed to defecate. These positions result in increased pressure on the abdomen and downward pressure on the rectum to facilitate defecation. Obtaining the same results when seated on a bedpan is difficult.

What is the micturition reflex? A) The process of filtration beginning with the glomerulus B) The act of bladder contraction and perceived need to void C) The reabsorption of the substances the body wants to retain D) The secretion of electrolytes that are harmful to the body

Ans: B Feedback: Several words are used to describe the process of excreting urine from the body, including urination, voiding, and micturition.

A client with a urinary tract infection is to be discharged from the health care facility. After teaching the client about measures to prevent urinary tract infections, the nurse determines that the education was successful when the client states which of the following? A) "I should take frequent bubble baths." B) "I need to void after sexual intercourse." C) "I should wipe from back to front after going to the bathroom." D) "I need to wear pants that are snug fitting."

Ans: B Feedback: The client's statement about voiding after sexual intercourse to prevent urinary tract infection is accurate. Taking frequent bubble baths, wiping the perineum from back to front, and wearing snug fitting pants increases the risk of urinary tract infection. The client should avoid taking frequent bubble baths, using harsh soaps, and wearing tight-fitting pants because they can irritate the urethra. The client also should always wipe from front to back after urinary or fecal elimination.

Which type of skills is not needed for nursing leadership? A) Communication skills B) Technical skills C) Problem-solving skills D) Self-evaluation skills

Ans: B Feedback: The four basic types of skills needed for nursing leadership are communication, problem solving, management, and selfevaluation. Technical skills are important to other nursing roles, but are not leadership skills.

During a home visit, the nurse learns that the client ensures a daily bowel movement with the help of laxatives. The client feels that deviation from a bowel movement every day is unhealthy. Which nursing diagnosis would the nurse most likely identify? A) Constipation B) Perceived constipation C) Risk of constipation D) Bowel incontinence

Ans: B Feedback: The most appropriate nursing diagnosis for the client is perceived constipation, because the client has made a selfdiagnosis of constipation and ensures a daily bowel movement through the abuse of laxatives. Constipation may be diagnosed in a client if there is a decrease in the normal frequency of defecation accompanied by a difficult or incomplete passage of stool (and/or passage of excessively hard, dry stool). Risk of constipation can be diagnosed if a client exhibits factors that predispose him or her for developing constipation. Bowel incontinence would be indicated if the client was experiencing an involuntary passage of stool.

A nurse leader is described as charismatic, motivational, and passionate. Communications are open and honest, and the nurse is willing to take risks. What type of leadership is the nurse practicing? A) Democratic B) Autocratic C) Quantum D) Transformational

Ans: D Feedback: Transformational leaders are often described as charismatic, challenging, and passionate about their vision. They communicate openly and honestly, show concern for others, and are willing to take risks.

During a staff meeting, the nurse is discussing new quantum leadership. The nurse explains that in this type of leadership change is viewed as which of the following? A) Constant and predictable B) Dynamic and constantly unfolding C) Evolving very slowly D) An entity needing planning

Ans: B Feedback: We are in a difficult transition period between the old and the new age. In the old age, change was viewed as an entity to be planned, carefully managed, and accepted. In the new quantum age, change is conceived as dynamic, ever-present, and continually unfolding.

A client tells the nurse, "I increased my fiber, but I am very constipated." What further information does the nurse need to tell the client? A) "Just give it a few more days and you should be fine." B) "Well, that shouldn't happen. Let me recommend a good laxative for you." C) "When you increase fiber in your diet, you also need to increase liquids." D) "I will tell the doctor you are having problems; maybe he can help."

Ans: C Feedback: A combination of high-fiber foods, 8 to 10 glasses of water a day, and exercise has been shown to be as effective as medications in controlling constipation. Caution the client to avoid increasing fiber intake without drinking enough fluids because this can lead to a bowel obstruction.

A nurse has catheterized a client to obtain urine for measuring postvoid residual (PVR) amount. The nurse obtains 40 mL of urine. What should the nurse do next? A) Report this abnormal finding to the physician. B) Perform another catheterization to verify the amount. C) Document this normal finding for postvoid residual. D) Palpate the abdomen for a distended bladder.

Ans: C Feedback: A postvoid residual (PVR) urine measures the amount of urine remaining in the bladder after voiding. It can be measured by catheterization or a bladder scan. A PVR of less than 50 mL indicates adequate bladder emptying. The nurse would document this normal finding for PVR.

Which type of stool would the nurse assess in a client with an illness that causes the stool to pass through the large intestine quickly? A) Hard, formed B) Black, tarry C) Soft, watery D) Dry, odorous

Ans: C Feedback: About 800 to 1,000 mL of liquid is absorbed daily by the large intestine. When absorption does not occur properly, such as when the waste products pass through the large intestine rapidly, the stool is soft and watery.

A nurse is educating a client on the amount of water to drink each day. What is the recommended daily fluid intake for adults? A) 1 to 2 (4-oz) glasses per day B) 5 to 6 (6-oz) glasses per day C) 8 to 10 (8-oz) glasses per day D) 16 to 20 (12-oz) glasses per day

Ans: C Feedback: Adults with no disease-related fluid restrictions should drink 2,000 to 2,400 mL (8 to 10 8-oz glasses) of fluid daily. Monitor fluid intake for those that are high in caffeine, sodium, and sugar.

The nurse is caring for a client who had a sudden episode of vomiting, which produced 900 mL of frank blood. The nurse directed and delegated to colleagues in order to notify the physician. She started intravenous fluids, and provided physical and emotional support for the client. Different situations call for different leadership styles. Which of the following leadership styles did the nurse display in this situation? A) Democratic B) Laissez-faire C) Autocratic D) Transformational

Ans: C Feedback: Autocratic leadership involves the leader assuming complete control. Democratic leadership displays a sense of equality among the leader and other participants. With laissez-faire leadership, the leader relinquishes power to the group. Transformational leaders create intellectually stimulating practice environments and challenge themselves and others to grow personally and professionally, and to learn.

A nurse is caring for older adult clients in an assisted-living facility. Which effect of aging should the nurse consider when performing a urinary assessment? A) The diminished ability of the kidneys to concentrate urine may result in urinary tract infection. B) Increased bladder muscle tone may reduce the capacity of the bladder to hold urine, resulting in frequency. C) Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract infect

Ans: C Feedback: Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract infection. The diminished ability of the kidneys to concentrate urine may result in nocturia (urination during the night). Decreased bladder muscle tone may reduce the capacity of the bladder to hold urine, resulting in increased frequency of urination. Neuromuscular problems, degenerative joint problems, alterations in thought processes, and weakness may interfere with voluntary control and the ability to reach a toilet in time. Individuals who view themselves as old, powerless, and neglected may cease to value voluntary control over urination, and simply find toileting too much bother no matter what the setting. Incontinence may be the result.

A nurse manager has directed a registered nurse who is out of school for one year to become a member of the institution's policy and procedure committee. A goal in the nurse manager's delegation is to assist the nurse to what? A) Be involved in the hospital B) Be confident in employment C) Grow in her profession D) Understand the hospital setting

Ans: C Feedback: Delegation of activities to staff members will assist them to grow and become more committed to their organization.

A hospitalized toddler, previously bowel trained, has been having incontinent stools. What would the nurse tell the parents about this behavior? A) "When he does this, scold him and he will quit." B) "I don't understand why this child is losing control." C) "This is normal when a child this age is hospitalized." D) "I will have to call the doctor and report this behavior."

Ans: C Feedback: Discourage the use of punishment or shame for elimination accidents. Toddlers who are toilet trained often regress and experience soiling when hospitalized, and scolding or acting disgusted only reinforces the behavior.

Which of the following is a characteristic of mentorship? A) It is a paid position to orient new nurses to the workplace. B) It involves membership in a professional organization. C) It is a link to a protégé with common interests. D) It is not encouraged in health care settings

Ans: C Feedback: Mentorship is a relationship in which an experienced individual (the mentor) advises and assists a less experienced individual (protégé). This is an effective way of easing a new nurse into leadership responsibilities. Mentors link with protégés by common interest and provide support, information, and network links. The relationship does not include financial reward. An alternative model is preceptorship. The preceptor (experienced nurse) is selected (and generally paid) to introduce an employee to new responsibilities through education and guidance.

A young woman comes to the emergency department with severe abdominal cramping and frequent bloody stools. Food poisoning is suspected. What diagnostic test would be used to confirm this diagnosis? A) Routine urinalysis B) Chest x-ray C) Stool sample D) Sputum sample

Ans: C Feedback: Outbreaks of food poisoning can result in severe gastrointestinal symptoms. Severe abdominal cramping followed by watery or bloody diarrhea may signal a microbial infection, which can be confirmed by a stool sample.

Which of the following statements accurately describes the use of power by change agents? A) They know that power comes from one source—management. B) When introducing change they do not enlist the support of key power players. C) They are often accomplished professional women. D) They do not recognize their own strengths and weaknesses.

Ans: C Feedback: Power,the ability to influence others to achieve a desired effect, has many sources. When introducing change, it is helpful to recognize and enlist the support of key power players who can then encourage others to become involved. Women are accomplished professionals and occupy powerful leadership positions in corporations, health care organizations, and political arenas. Nursing leaders recognize the strengths and limitations of their own power and encourage others to develop and use power constructively.

A nurse is preparing to catheterize a female client. What will the nurse consider when comparing the anatomy of the female urethra with that of the male urethra? A) Has different innervation B) No connection with bladder C) Shorter in length D) Longer in length

Ans: C Feedback: The anatomy of the urethra differs in males and females. The male urethra is about 51/2 to 61/4 inches (13.7 to 16.2 cm) long. The female urethra is about 11/2 to 21/2 inches (3.7 to 6.2 cm) long. This difference is important in terms of catheterization and risk for infection.

A nurse is considering the delegation of administering medications to an unskilled assistant. What is the first question the nurse must ask herself before doing so? A) Has the assistant been trained to perform the task? B) Have I evaluated the client's response to this task? C) Is the delegated task permitted by law? D) Is appropriate supervision available?

Ans: C Feedback: The first question the nurse should always consider before delegating a task is "Is the delegated task permitted by law?" In this case, it would not be, and the task (administering medications) would not be delegated.

A nurse is providing care to a client who has undergone a colonoscopy. Which of the following would be most appropriate for the nurse to do after the procedure? A) Avoid giving solid food B) Administer a laxative to the client C) Monitor for rectal bleeding D) Limit oral fluid intake

Ans: C Feedback: The nurse should monitor the client for rectal bleeding after a colonoscopy. The nurse should provide rest and offer food and fluids as allowed. The evening before the procedure, solid foods are avoided and liquids are encouraged. Laxatives are also given before the procedure.

A nurse uses a catheter to collect a sterile urine specimen from a client at a health care facility. If a catheter is required temporarily, which type of catheter should the nurse use? A) Condom catheter B) Urinary bag C) Straight catheter D) Retention catheter

Ans: C Feedback: The nurse should use a straight catheter to collect a sterile urine specimen from the client. A straight catheter is a urine drainage tube inserted but not left in place. It drains urine temporarily or provides a sterile urine specimen. Condom catheters are helpful for clients with urinary incontinence receiving care at home, because they are easy to apply. A urinary bag is more often used to collect urine specimens from infants. A retention catheter, also called an indwelling catheter, is left in place for a period of time.

A nurse working in a community pediatric clinic explains the process of toilet training to mothers of toddlers. Which is a recommended guideline for initiating this training? A) The child should be able to hold urine for four hours. B) The child should be between 18 and 24 months old. C) The child should be able to communicate the need to void. D) The child does not need the desire to gain control of voiding.

Ans: C Feedback: Voluntary control of the urethral sphincters occurs between 18 and 24 months of age. However, many other factors are required to achieve conscious control of bladder function, and toilet training usually begins at about 2 to 3 years of age. Toilet training should not begin until the child is able to hold urine for two hours, recognize the feeling of bladder fullness, communicate the need to void, and control urination until seated on the toilet. The child's desire to gain control is also important.

An infant has had diarrhea for several days. What assessments will the nurse make to identify risks from the diarrhea? A) Heart tones B) Lung sounds C) Skin turgor D) Activity level

Ans: C Feedback: When infants and children become ill, they lose most fluids from their extracellular compartment, which quickly leads to dehydration. The nurse would assess skin turgor to identify this problem

Which of the following statements accurately describes recommended guidelines for overcoming resistance to change? Select all that apply. A) Explain the proposed changes only to the managers of the people involved. B) Whenever possible, use technical language to describe the changes. C) List the advantages of the proposed change for members of the group. D) Avoid relating the change to the group's existing beliefs and values. E) If possible, introduce change gradually.

Ans: C, E Feedback: To overcome resistance to change, the nurse should explain the proposed change to all affected people in simple, concise language; list the advantages of the proposed change, both for the individual and for members of the group; relate the proposed change to the person's (or group's) existing beliefs and values; if possible, introduce change gradually; provide incentives for commitment to change such as money, status, time off, or a better working environment.

The following foods are a part of a client's daily diet: high-fiber cereals, fruits, vegetables, 2,500 mL of fluids. What would the nurse tell the client to change? A) Decrease high-fiber foods B) Decrease amount of fluids C) Omit fruits if eating vegetables D) Nothing; this is a good diet

Ans: D Feedback: A high-fiber diet and a daily fluid intake of 2,500 to 3,000 mL of fluids facilitate bowel elimination. Intake of the foods described makes the feces more bulky, so they move through the intestine more quickly. The stool is softer and the time to absorb toxins is decreased (toxins are believed to have a role in the development of colon cancer).

A nurse is carrying out an order to remove an indwelling catheter. What is the first step of this skill? A) Deflate the balloon by aspirating the fluid. B) Ask the client to take several deep breaths. C) Tell the client burning may initially occur. D) Wash hands and put on gloves.

Ans: D Feedback: Although all the steps listed are correct, the first step of any skill involving body fluids is to wash hands and don gloves.

A nurse manager makes all of the decisions for staff activities. What type of leadership is demonstrated by this action? A) Democratic B) Self-governance C) Laissez-faire D) Autocratic

Ans: D Feedback: Autocratic leadership involves the leader assuming complete control over the decisions and activities of the group. An extremely autocratic leader might make all decisions for workers without considering their ideas or feelings.

A nurse working on leadership skills should keep in mind which of the following accurate statements regarding leaders? A) People are born leaders. B) Leadership should be approached quickly. C) Leaders develop leadership skills in undefined situations. D) All nurse leaders began as inexperienced nurses.

Ans: D Feedback: Leadership should be approached like any other new role or skill: slowly and carefully. Nursing students and beginning nurses should be prepared with all of the necessary tools or skills before attempting the new role. Initially, nurses develop leadership skills in well-defined clinical situations. With each experience, growth occurs and leadership is strengthened. All nurse managers, nurse administrators, and nursing leaders also began as inexperienced nurses.

In which of the following conflict resolution strategies is the conflict rarely resolved? A) Collaborating B) Compromising C) Competing D) Smoothing

Ans: D Feedback: Smoothing is an effort to complement the other party and focus on agreement rather than disagreement, thus reducing the emotion in the conflict. The original conflict is rarely resolved with this technique.

A client who has been on a medication that caused diarrhea is now off the medication. What could the nurse suggest to promote the return of normal flora? A) Stool-softening laxatives, such as Colace B) Increasing fluid intake to 3,000 mL/day C) Drinking fluids with a high sugar content D) Eating fermented products, such as yogurt

Ans: D Feedback: Some medications, such as antibiotics, may destroy normal intestinal flora and cause diarrhea. To promote the return of normal flora, the nurse can recommend an intake of fermented dairy products, such as buttermilk or yogurt.

A school nurse is educating a class of middle-school girls on how to promote urinary system health. Which of the following statements by one of the girls indicates a need for more information? A) "I will take showers rather than baths." B) "I will wear underpants with cotton crotches." C) "I will tell my parents if I have burning or pain." D) "I will wipe back to front after going to the toilet."

Ans: D Feedback: Teaching about measures to promote urinary system health is a major nursing responsibility. Measures include drying the perineal area after urination or defecation from the front to the back (or from urethra to rectum).

A nurse believes in listening to clients and coworkers more than talking to them, allowing more personal control for all involved. This is a quality of which of the following managerial mindsets? A) Reflective B) Analytical C) Worldly D) Collaborative

Ans: D Feedback: The collaborative mindset involves listening more than talking, and allowing people to take initiative and control their own work. The reflective mindset allows managers to mentally digest experiences and reflect on them in a different way. The analytical mindset encourages introspection so that one can recognize biases and see things in a unique way. This facilitates a change in course and movement toward resolution of problems. The worldly mindset recognizes cultures and contexts or "seeing differently out to reflect differently in."

the past. An audit of incident reports has confirmed this, and the nursing leadership has recognized the need to make changes to reduce the incidence of falls. How should the leaders proceed with this planned change? Place the following steps in the correct order. 1. Implement the change in nursing practice. 2. Choose a new protocol that is likely to reduce falls. 3. Take measures to ensure that nursing practice does not revert. 4. Determine and analyze different solutions to the problem. 5. Dev

Ans: D Feedback: The eight-step program of planned change is similar to the nursing process of assessment, diagnosis, planning, implementation, and evaluation. After this process, measures are taken to ensure that the change is stabilized and made permanent.

A nurse is caring for a client who is being treated for bladder infection. The client complains to the nurse that he has been having difficulty voiding and feels uncomfortable. How should the nurse document the client's condition? A) Anuria B) Oliguria C) Polyuria D) Dysuria

Ans: D Feedback: The nurse could document the client's condition as dysuria, which is difficulty or discomfort when voiding. Dysuria is a common symptom of trauma to the urethra or bladder infection. Anuria means absence of urine or a volume of 100 mL or less in 24 hours. Oliguria indicates inadequate elimination of urine. Polyuria is the term used to indicate greater than normal urinary volume, and may accompany minor dietary variations.

A nurse is assessing the stoma of a client with an ostomy. What would the nurse assess in a normal, healthy stoma? A) Pallor B) Purple-blue C) Irritation and bleeding D) Dark red and moist

Ans: D Feedback: The ostomy stoma should be dark pink to red and moist. Abnormal findings include paleness (possible anemia), purpleblue color (possible ischemia), or bleeding.

A nurse is conducting an abdominal assessment. What is the rationale for palpating the abdomen last in the sequence when conducting an abdominal assessment? A) It is the most painful assessment method B) It is the most embarrassing assessment method C) To allow time for the examiner's hands to warm D) It disturbs normal peristalsis and bowel motility

Ans: D Feedback: The sequence for abdominal assessment is inspection, auscultation, percussion, and palpation. Inspection and auscultation are performed before palpation because palpation may disturb normal peristalsis and bowel motility.

A nurse is preparing a client for an invasive diagnostic procedure of the urinary system. What statement by the nurse would help reduce the client's anxiety? A) "We do these procedures every day, so you don't need to worry." B) "I have had this done to me, and it only hurt for a little while." C) "Why are you so worried? Do you think you have a tumor?" D) "Let me explain to you what they do during this procedure."

Ans: D Feedback: Various diagnostic procedures, typically performed in a hospital operating room or outpatient facility, are used to study the urinary system. Nurses are responsible for preparing the client and giving aftercare. Explaining the procedure helps reduce the client's anxiety.

A student is collecting a sterile urine specimen from an indwelling catheter. How will the student correctly obtain the specimen? A) Pour urine from the collecting bag. B) Remove the catheter and ask the client to void. C) Aspirate urine from the collecting bag. D) Aspirate urine from the collection port.

Ans: D Feedback: When it is necessary to collect a urine specimen from a client with an indwelling catheter, it should always be obtained from the catheter itself using the special collection port.